Asthma and Inhalant Allergens

National Center for Environmental HealthDivision of Environmental Hazards and Health

Effects

National Asthma Education and Prevention Program (NAEPP) Guidelines for the Diagnosis and Management of Asthma:

“Exposure of patients who have asthma to allergens … to which they are sensitive has been shown to increase asthma symptoms and precipitate asthma exacerbations. (Evidence A)”

Allergens Can Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Inhalant Allergens Are Important in Asthma

From NAEPP guidelines:“The important allergens for children and

adults appear to be those that are inhaled.”

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Objectives

Describe how inhalant allergens affect asthma

Describe types of inhalant allergens Review NAEPP recommendations

Evaluation of inhalant allergens for persons with asthma Environmental control of inhalant allergens

HOW INHALANT ALLERGENS AFFECT ASTHMA

Definitions

Allergen Substance that causes the immune system to overreact Also known as “allergic trigger” Examples: pollen, shellfish, antibiotics, poison ivy

Definitions

Allergen Substance that causes the immune system to overreact Also known as “allergic trigger” Examples: pollen, shellfish, antibiotics, poison ivy

Inhalant allergen

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

IgE antibody

How Inhalant Allergens Affect Asthma

Sensitized

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

IgE antibody

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

IgE antibody

Eosinophil

Histamine

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

IgE antibody

Eosinophil

Histamine: antihistamine

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

No inflammation or obstruction in airways insensitive to allergens

How Inhalant Allergens Affect Asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed.

Inhalant allergens

Enters airways

Inflammation and obstruction in airways sensitive to allergens

No inflammation or obstruction in airways insensitive to allergens

Allergic

Not allergic

TYPES OF INHALANT ALLERGENS

Inhalant Allergens

Inhalant Allergens

Indoor allergens Furry animal pets

Cats Dogs Rabbits Hamsters Guinea pigs

Inhalant Allergens

Indoor allergens Furry animal pets Mice Cockroaches

Inhalant Allergens

Indoor allergens Furry animal pets Mice Cockroaches House dust mites

Inhalant Allergens

Outdoor allergens Trees

Inhalant Allergens

Outdoor allergens Trees Grasses

Inhalant Allergens

Outdoor allergens Trees Grasses Weeds

Inhalant Allergens

Mold allergens Outdoors Indoors

Inhalant Allergens

pollen.aaaai.org/nab

Outdoor allergens Trees Grasses Weeds Molds

Inhalant Allergens Summary

Indoor OutdoorIndoor or Outdoor

Inhalant Allergens Summary

Indoor Indoor or Outdoor

Seasonal

Outdoor

Inhalant Allergens Summary

Indoor Indoor or Outdoor

Seasonal

Perennial*

Outdoor

*Some indoor inhalant allergens can exhibit seasonal variation

EVALUATION OF INHALANT ALLERGENS

Who Should Be Evaluated?

From NAEPP guidelines:“The Expert Panel recommends that patients

who have asthma at any level of severity should be queried about exposures to inhalant allergens, particularly indoor inhalant allergens, and their potential effect on the patient’s asthma. (Evidence A)”

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Who Should Be Evaluated?

From NAEPP guidelines:“The Expert Panel recommends that patients

who have asthma at any level of severity should be queried about exposures to inhalant allergens, particularly indoor inhalant allergens, and their potential effect on the patient’s asthma. (Evidence A)”

(emphasis added)

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Inhalant Allergens and Persistent Asthma

For at least those patients who have persistent asthma, the clinician should evaluate the potential role of allergens, particularly indoor inhalant allergens (Evidence A):

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Inhalant Allergens and Persistent Asthma

For at least those patients who have persistent asthma, the clinician should evaluate the potential role of allergens, particularly indoor inhalant allergens (Evidence A): Use the patient’s medical history to identify

allergen exposures that may worsen the patient’s asthma

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Inhalant Allergens and Persistent Asthma

For at least those patients who have persistent asthma, the clinician should evaluate the potential role of allergens, particularly indoor inhalant allergens (Evidence A): Use the patient’s medical history to identify

allergen exposures that may worsen the patient’s asthma

Use skin testing or in vitro testing to reliably determine sensitivity to perennial indoor inhalant allergens to which the patient is exposed

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Inhalant Allergens and Persistent Asthma

For at least those patients who have persistent asthma, the clinician should evaluate the potential role of allergens, particularly indoor inhalant allergens (Evidence A): Use the patient’s medical history to identify

allergen exposures that may worsen the patient’s asthma

Use skin testing or in vitro testing to reliably determine sensitivity to perennial indoor inhalant allergens to which the patient is exposed

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Inhalant Allergens and Persistent Asthma

For at least those patients who have persistent asthma, the clinician should evaluate the potential role of allergens, particularly indoor inhalant allergens (Evidence A): Use the patient’s medical history to identify

allergen exposures that may worsen the patient’s asthma

Use skin testing or in vitro testing to reliably determine sensitivity to perennial indoor inhalant allergens to which the patient is exposed

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

(emphasis added)

Inhalant Allergens Tested Can Vary

By residential area Geographic region Urban, suburban, or rural

By individual circumstances Pets Work exposures

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Middleton’s Allergy 7th Ed. , 2009

CONTROL OF INHALANT ALLERGENS

NAEPP Components of Asthma Management

1) Measures of asthma assessment and monitoring

2) Education for a partnership in asthma care3) Control of environmental factors and

comorbid conditions that affect asthma— Inhalant allergens

4) Medications

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

NAEPP Management of Inhalant Allergens

Patients who have asthma at any level of severity should: Reduce, if possible, exposure to allergens to

which the patient is sensitized and exposed Know that effective allergen avoidance

requires a multifaceted, comprehensive approach; individual steps alone are generally ineffective (Evidence A)

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Management of Furry Animal Pets

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

If the patient is sensitive to the animal, the treatment of choice is removal of the exposure from the home

If removal of the animal is not acceptable: Keep the pet out of the patient’s bedroom Keep the patient’s bedroom door closed

Management of Animal Pests

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Portnoy et al., JACI, 2012; Portnoy et al., JACI, 2013; Kass et al., Environ Health Perspect, 2009

Physical ChangesKitchen and Bathroom• Cleaning*

• Pesticide application (low toxicity)

• Sealing cracks and holesPatient’s Bedroom• Cleaning*

• Pesticide (low toxicity) EducationClean up spillsEat only in kitchenUse sealed food containersDispose of trash frequently

Integrated Pest Management (IPM)

*Cleaning to remove dead cockroaches, cockroach fecal pellets, or mouse urine that could contain allergens

Management of House Dust Mites

Encase mattress and pillow(s) in allergen-impermeable covers

Wash sheets and blankets weekly

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Portnoy et al., Ann Allergy Asthma Immunol, 2013

Management of House Dust Mites

Encase mattress and pillow(s) in allergen-impermeable covers

Wash sheets and blankets weekly

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Portnoy et al., Ann Allergy Asthma Immunol, 2013

Management of House Dust Mites

Encase mattress and pillow(s) in allergen-impermeable covers

Wash sheets and blankets weekly

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Portnoy et al., Ann Allergy Asthma Immunol, 2013

Management of House Dust Mites

Encase mattress and pillow(s) in allergen-impermeable covers

Wash sheets and blankets weekly

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Portnoy et al., Ann Allergy Asthma Immunol, 2013

Management of House Dust Mites

Encase mattress and pillow(s) in allergen-impermeable covers

Wash sheets and blankets weekly

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; Portnoy et al., Ann Allergy Asthma Immunol, 2013

Management of Indoor Molds

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007; www.cdc.gov/mold

Decrease indoor humidity to <50% Ventilate bathrooms and kitchens Repair leaks Address water condensation problems

When possible, stay indoors with windows closed in an air-conditioned environment during peak pollen season

Management of Outdoor Inhalant Allergens

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, 2007

Conclusions

Inhalant allergens cause airway inflammation, hyperresponsiveness, and obstruction

Indoor allergens include furry animal pets, mice, cockroaches, house dust mites, and molds

Outdoor allergens include molds, as well as pollens from trees, grasses, and weeds

Outdoor allergens vary by season and geography

Conclusions

All persons with asthma should be queried regarding exposures to inhalant allergens Potential effect on asthma Importance of indoor inhalant allergens

Allergy testing can reliably determine sensitivity to inhalant allergens

Reduced allergen exposure can benefit sensitive individuals

Effective allergen avoidance requires a multifaceted, comprehensive approach

Additional Resources

Expert panel report 3: guidelines for the diagnosis and management of asthma (EPR 3 2007). ⎯ NIH Publication No. 07-4051. Bethesda, MD: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, 2007.

www.cdc.gov/asthma/public_health.html Home-based Multi-trigger, Multi-component

Environmental Interventions Asthma: A Presentation of Asthma Management and

Prevention www.cdc.gov/mold

CDC, Asthma: A Presentation of Asthma Management and Prevention, http://www.cdc.gov/asthma/speakit/default.htm

EPR 3. Expert panel report 3: guidelines for the diagnosis and management ⎯of asthma (EPR 3 2007). NIH Publication No. 07-4051. Bethesda, MD: U.S. ⎯Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, 2007.

Chew GL, et al. Mold and endotoxin levels in the aftermath of Hurricane Katrina: a pilot project of homes in New Orleans undergoing renovation. Environ Health Perspect. 2006 Dec;114(12):1883-9.

Esch, Robert E. and Bush, Robert K. Middleton’s Allergy. 7th Ed. Ed. N. Franklin Adkinson Jr. et al. Philadelphia: Mosby, 2009.

Kass D, et al. Effectiveness of an integrated pest management intervention in controlling cockroaches, mice, and allergens in New York City public housing. Environ Health Perspect. 2009 Aug;117(8):1219-25.

Portnoy J, et al. Environmental assessment and exposure control of dust mites: a practice parameter. Ann Allergy Asthma Immunol. 2013 Dec;111(6):465-507.

Portnoy J, et al. Environmental assessment and exposure reduction of cockroaches: a practice parameter. J Allergy Clin Immunol. 2013 Oct;132(4):802-8.e1-25.

Portnoy J, et al. Environmental assessment and exposure control: a practice parameter —furry animals. Ann Allergy Asthma Immunol. 2012 Apr;108(4):223.e1-15.

References